Will Tech Save Healthcare?

Although digital health offers new opportunities, it is not a panacea for all healthcare challenges – argues Professor Ilona Kickbusch, one of the strongest voices in global health, the founding Director of the Global Health Centre at the Graduate Institute of International and Development Studies. We discuss the benefits of new technologies and the unrealistic expectations of digitization.

Professor Kickbusch, in your opinion, “we do not look deeply enough at the radical impact of the digital transformation on our health and life.” What do you mean by that?

The digital transformation of health has largely been portrayed as a technology-driven process where people merely have to adapt to a new normal. It sometimes appears as if these digital technologies would come per se with a new way of doing things. While maybe true with some technologies, we should be careful in simply accepting this paradigm.

Don’t get me wrong, the opportunities of digital technologies are tremendous. Take the example of M-TIBA, a digital platform which was developed by both PharmAccess (a non-profit organization) and Safaricom (a mobile money operator and mobile payment platform). In Kenya, it has connected four million people and 1400 health clinics, allowing the quick and efficient transfer of healthcare payments. More importantly from a public health perspective, it will enable the connection to national health programmes and insurance. As such, the opportunity is to improve on a long-standing goal: to allow more people access to health care without suffering from unbearable financial burdens.

In contrast, if we look into some of the digital innovations that are hailed as ground breaking in many high-income countries, the added value of the tools is questionable. For example, I share the hope that digital interventions that support clinical practice and act as “health-care companions” can provide real health gains. However, when fitness and healthy lifestyle trackers are referred to as the solution to fight the staggeringly high obesity prevalence, then we are overestimating the potential of technology to break through the social and commercial determinants of health.

If we allow the digital transformation of health to become the driver of higher individualization of healthcare while ignoring the wider determinants of health, we are undermining the right to health.

The Singapore government partners with Apple on a national health program to encourage healthy behaviors using Apple Watch. Do you think this is the future of population health and preventive programs? Is such a partnership with a big tech company a move in the right direction?

I am absolutely convinced that digital interventions will be an important cornerstone of public health. Government policy should support healthy lifestyles just as we have done for decades as part of health promotion. And if digital tools support these policies, even better!

Having said that, it’s useful to remember how The Ottawa Charter for Health Promotion (WHO, 1986) framed the challenge of improving population health, whereby health is created in the context of everyday life, where people live, love, work and play. Amidst the digital transformation of our societies, we must not only accept that many of our activities happen in the digital context, but we must also add more verbs to describe everyday behavior: to google, to tweet, to stream. Looking at population health and preventive programs with this perspective, it is evident that the digital realm needs to be co-shaped along with public health policy and supportive environments. We cannot neglect that digital technologies and the processes they engender in everyday life are themselves determinants of health. Research on mental health is showing us the way here.

Partnerships are important to support innovation, but policy makers need to ensure who they are in these partnerships. They hold the key to a tremendously valuable good – the personal data of citizens. In their best interest, they need to forge necessary partnerships. I don’t think that this message has arrived with all governments.

Prior to the COVID-19 pandemic, most public health institutions – following my observations – distrusted digital health technologies. On the one hand, we have innovators quickly trying to bring their solutions to the market. On the other hand, the academic world is focused on evidence-based interventions. Can these two worlds be reconciled?

It’s useful to take a step back and acknowledge the context. The health economy is made up of a complex interplay of actors: between people aspiring to improve their health, care providers, pharmaceutical and health care producers as well as governments. In many countries, all this is embedded into a system of health insurance and a broader redistributive system. There are important reasons why health cannot and should not be treated like any other good. What we are experiencing now is the interface between health and the digital economy and a new pressure on health care systems.

We have witnessed that some digital companies have shaken up markets not just through innovation but by neglecting established laws and social norms. I believe public health institutions are well-advised to double-check what deal they strike with technology companies.

And I see this approach developing some speed. Some of the policies coming from the German Ministry of Health are interesting in this regard. The Digital Health Care Act (Digitale-Versorgung-Gesetz, or DVG), for example, formalizes a pathway to “prescribable applications”. It includes a standardized review process of health apps. If an app fulfills some requirements, f.e. data protection, information security, interoperability, and preliminary data on the benefits that the app provides, it is listed in a central registry. Such solutions can be prescribed by physicians and psychotherapists, and reimbursed by the health insurance providers. As I said, the health economy has to follow different rules, but they can be shaped by policies to become more innovative and socially responsible. Adding public value must be the key orientation.

COVID-19 is the “first pandemic of the digital age.” Have we made the best use of new technologies to strengthen epidemiological surveillance? What could be done better?

On a global scale, the discussion around COVID-tracking has allowed us a glimpse into what could be called “varieties of digital transformation.” Depending on the institutional setup, countries took quite diverging pathways.

At least for European countries, we can safely say that we are just beginning to realize the potential of digital technologies for epidemiological surveillance. But to develop more effective surveillance, we need to overcome simplistic discussion such as “more safety will always come with an infringement of civil liberties.” The COVID-19 contact tracing apps are a case in point. Rather than saying outright that they will infringe on privacy, the discussion should revolve around the question of “what safeguards do need to be in place to accept the tool as a contribution to a solid health system”? I think we can learn a lot from Taiwan in this regard.

The major improvement to pandemic preparedness won’t come from digital technologies, though. On a national level, a lot can be learned from countries that prepared their public health emergency systems after the SARS/MERS outbreaks. Strengthening the public health systems with more resources as well as with policies is essential. This could be the start of a digital transformation of public health moving us towards new approaches to health intelligence and a new ecosystem of connected information and solutions.

From a global health perspective, I would certainly say that the highest priority is to equip the WHO with the necessary resources to live up to the high expectations towards the organization. This also involves the support to low- and middle-income countries to build the capacities that shape pandemic preparedness. And that, of course, includes addressing information, technology and infrastructure gaps.

The gap between healthcare capacity and demand for health and well-being services is growing. Is it reasonable to think that digitization can reduce this imbalance? 

Digitization alone will certainly not solve the inefficiency problems health systems have – this issue must be dealt with at a much more fundamental level (e.g., prices of pharmaceutical products). On the supply side, it is especially the shortage of healthcare workers that creates a tremendous problem that will hardly be solved by intelligent robots any time soon.

At the same time, if embedded into a broader policy framework, digital technologies (and also AI-driven tools) will have an important role to play in supporting doctors and nurses in their everyday work, in supporting patients and helping people live healthier lives, and in building health systems that spend fewer resources on administrative processes.

What does the term “sustainable health care” mean to you? What are the pillars of resilient healthcare systems?

I prefer to speak of sustainable health – in very close reference to the Sustainable Development Goals. This implies a very strong focus on equity and leaving no one behind. We need a focus on the determinants of health and well-being. There is also a very vibrant debate on sustainable health systems, which again is broader than just focusing on care and includes the public health functions that are often neglected. This debate often uses the triple aim concept to describe the aims of a sustainable health system. These are to improve population health, improve the patient experience of care (including quality and satisfaction) and reduce the per capita cost of care. This is not dissimilar to “resilient” health systems, which are focused on access to primary health care, financial protection and support of vulnerable groups – and thus more likely to withstand external shocks – as in the case of the COVID-19 pandemic.

The pandemic has thrown a brutal light on weak and unfair systems. It has also shown, that resilience is no longer enough – it also requires agile systems that can respond quickly according to new needs.

Professor Kickbusch, where does your passion for global health come from?

That’s always very hard to answer. I grew up in India and was confronted with inequality as a child, which left a big, lasting impression. Not being a physician but a political scientist, I found my own way to contribute by focusing on the determinants of health and the governance of global challenges.

If you could name the most common mistake in healthcare policies today, what would it be?

Again, I am more interested in health policy than healthcare policy – and that is actually the biggest mistake right there. Many decision-makers focus too much on care rather than on what keeps people healthy.

What critical decisions should be made at the global health level this year?

The defining issue is the equitable distribution of COVID-19 vaccines. Several decisions need to be made in that respect – political and financial. Another critical development is the proposal for pandemic preparedness treaty. If done well, it could be a game-changer.

---